2020 BENEFIT GUIDE - MYMEMBERSHIP offers a ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
2020 BENEFIT GUIDE
CONTENT
04 URGENT CONTACT
04 ALLIANCE-MIDMED MOBILE APP
04 WHO WE ARE
05 MEMBERSHIP
05 SCHEME AND BENEFIT DESIGN
06 EMERGENCIES AND TRAUMA BENEFIT
07 BENEFITS
12 HEALTH MANAGEMENT
14 ENHANCEMENTS
16 IMPORTANT BENEFIT MANAGEMENT MATTERS
18 ADMINISTRATION AND SELF-HELP
20 TERMINOLOGY
20 EXCLUSIONS
20 ABBREVIATIONS
IMPORTANT NOTES:
• Unless otherwise stated, all claims will be paid at 100% of the Alliance-MidMed Rate
• This benefit guide is for information purposes only and does not supersede the Rules of the Scheme
• In the event of any discrepancy between the benefit guide and the Rules, the Rules will prevail. The Rules are
available on the Scheme’s website www.alliancemidmed.co.za
• Scheme exclusions and limitations apply. A list of exclusions can be found on the Scheme
website www.alliancemidmed.co.zaURGENT CONTACTS
24-HOUR MEDICAL CALL CENTRE FRAUD HOTLINE
EMERGENCY EVACUATION
0860 00 2101 0860 04 0040
0860 25 5426 SERVICE@ALLIANCEMIDMED.CO.ZA MAIL@BEHEARD.CO.ZA
PO BOX 1463, FAERIE GLEN, PRETORIA, 0043
CONNECT AND COMMUNICATE
Please do not hesitate to contact any of the following for friendly and speedy service:
TELEPHONE OTHER CONTACT DETAILS
Ambulance services and health counselor 0860 25 5426 Dedicated Call Line
service@alliancemidmed.co.za
Call centre 0860 00 2101
www.alliancemidmed.co.za
Pre-authorisation 0860 00 2101, select option 3 auths@alliancemidmed.co.za
Health professional pre-authorisation major
0860 00 2101, select option 3 auths@alliancemidmed.co.za
medical and hospital benefits
Four Stones Office Park, 21 Dolerite Crescent,
Middelburg office 0860 00 21 01
Aerorand, Middelburg, Mpumalanga
0860 00 2101, select option 3 Sister Katie Janse van Rensburg
Nursing team
0860 00 2101, select option 3 Sister Webson Madawo
Medicine claims enquiries 0860 11 3238 info@mediscor.co.za
preauth@mediscor.co.za
www.mediscor.co.za
Chronic medication authorisation 0860 11 9553
(To view medicines paid by the Scheme
and co-payments)
clinical@alliancemidmed.co.za
Confidential HIV/AIDS programme 0860 00 2101, select option 2
info@mediscor.co.za
Savings refunds 0860 00 2101, select option 1 service@alliancemidmed.co.za
0860 00 0702 allianceenq@denis.co.za
Denis - Dental management
0866 77 0336 www.denis.co.za
Replacement cards 0860 00 2101, select option 1 service@alliancemidmed.co.za
Fraud hotline 0860 04 0040 mail@beheard.co.za
www.play.google.com or
Mobile App
www.myistore.co.za
Service concerns 0828 01 3323 jhhartz@outlook.com
ALLIANCE-MIDMED MOBILE APP
Most interactions with the Scheme could be completed through the Mobile App. Download the Mobile App for free from the Google Play or the App
Store on your smartphone or tablet.
Use the Mobile App for convenient and easy access to emergency and key contact details, checking benefits, requesting pre-authorisation,
statements, savings balances, submitting claims, verifying your membership, and other great features.
You can use the same username and password for web access (www.alliancemidmed.co.za) and the Alliance-MidMed Mobile App.
Please contact us at 0860 00 2101 or service@alliancemidmed.co.za if you require assistance with the download or registration on the Mobile App.
DOWNLOADS
Download various documents from the Scheme website – www.alliancemidmed.co.za, including this benefit guide, membership change forms,
banking confirmation forms, etc.
WHO WE ARE!
Alliance-MidMed Medical Scheme was registered as a closed scheme in 1974. Membership is limited to the employees of Columbus Stainless
and its associate companies that allow continued employee membership to the Scheme. The aim is to provide healthcare benefits that serve the
members’ needs.
We are a traditional non-profit Scheme with a small savings account and benefits that focus on the quality of, and access to, appropriate healthcare.
Benefits are personalised and administered in-house. We use a world-renowned team to ensure quality cover and partners with selected third parties
to ensure delivery of the highest levels of service excellence. Our team is passionate about healthcare.
Most of our members are based in Middelburg, Mpumalanga, but we provide benefits throughout South Africa via various agreements with
Health Professional organisations and claims management providers.
Alliance-MidMed is managed by a Board of six Trustees, three of whom are appointed by the employer and three who are elected by the members.
The Boards’ task is to determine the Rules that govern the Scheme, the benefits and the contributions while ensuring the financial sustainability of
the Scheme and equitable access to benefits for all members.
4WHAT WE DO
We fund access to quality healthcare through superior benefit design along with financing that promotes health, wellbeing and supports partnerships.
Our personal wellness and appropriate care focus consistently assure top medical care at an affordable cost. Some of our difference includes:
Cover anywhere in South Africa Unlimited hospital benefit 24/7 Medical access Health and wellness focus
Top chronic options Rich medicine advantage Lowest out-of-pocket costs Custom benefits
We manage benefits through benefit design, financial limits, limiting the number of benefit access limits (e.g. no of GP visits, the maximum number of
painkillers, etc.), co-payments, pre-authorisation, management programmes, exclusions, and directing access to quality care. For more information,
please contact us on 0860 00 2101 or service@alliancemidmed.co.za.
The Scheme actively engage with our members to assess your risk and empower you to manage and prevent health events that could have a long-
term negative effect. The Know Your Numbers – Know Your Health Risks programme aims at improving the quality of life and reducing the cost of
healthcare in the medium term. Our Professional Nurses will provide more information.
MEMBERSHIP
Our members are the employees of Columbus Stainless and associated companies and their dependants. Register your spouse (legal or custom),
life partner, own, step or legally adopted children under the age of 21, and immediate family for whom you are liable for family care and support.
Adult rates apply for dependants over 21 and proof of dependency and relationships are required. If your employer continues to participate in the
Scheme fully and you have been a member of either the Alliance-MidMed Scheme or another Scheme for the five consecutive years, you will be
allowed to remain a member after retirement.
We are a closed Scheme; therefore, membership terminates when you resign from your employer or the Scheme while you work at the same employer.
We require one calendar month’s written notice, sent to us via your employer. We will terminate your membership if you do not pay amounts due, or
if you or your dependants commit fraud. Your ex-spouse does not qualify for membership and removal of your spouse before divorce finalisation,
require completion of an “Instruction to Remove a Dependant” form.
When the principal member passes on, their dependants may choose to remain members of the Scheme. Surviving spouses may remain members
of the Scheme, if they:
• are registered as dependants at the time of the member’s death,
• can prove that his/ her employer does not provide for medical scheme membership;
• the deceased principal member has been a member of either Alliance-MidMed or another Scheme for five consecutive years.
Should the surviving spouse remarry, membership of the Scheme will terminate.
Pensioners or surviving spouses who wish to terminate their membership must notify the Scheme in writing.
Notify us of marital status changes, birth or legal adoption of a child, dependants who no longer qualify for membership, address changes and bank
account changes, by using our standard forms. Please note the payroll dates when you submit documentation that must be verified by the employer.
Bank account changes require verifications like those at your bank.
You must complete a health questionnaire when you apply for membership and when you apply to join dependants. The questionnaire is a legal
document and non-disclosure, or incomplete responses can cause termination of membership. (You are responsible to ensure completeness and
accuracy of the required information).
We charge late-joiner penalties, and exclusions and waiting periods apply to protect the interests of the Scheme and all members.
Contact us at 0860 00 2101 or service@alliancemidmed.co.za for more information, or refer to www.alliancemidmed.co.za.
SCHEME AND BENEFIT DESIGN
A. MAIN FEATURES
Alliance-MidMed offers a traditional benefit option with a compulsory 5% Personal Medical Savings Account (PMSA). Benefits are paid either through
the Major Medical Pool (MMP), the Life Stages Benefit (LSB) or through your Personal Medical Savings Account (PMSA).
B. ACCESS TO BENEFITS
When we approve your membership, you will receive a membership card. Your membership card reflects your membership number, yours and your
registered dependant’s names and dates of birth and the dates from when you are entitled to benefits. Please keep your card safe and do not lend it
to anyone as fraudulent use of cards may lead to the suspension or termination of your membership.
To access your benefits, show your membership card to the healthcare professional. If they have questions or queries, ask them to call us
on 0860 00 2101.
5If you join the Scheme within 30 days of employment no underwriting applies, but Late Joiner Penalties will apply. Contact us on 0860 00 2101 or
service@alliancemidmed.co.za for more information.
Benefits are available in the following broad categories. More information can be found below in the Benefits section and Annexure B of the
Scheme Rules.
C. MAJOR MEDICAL POOL
CATEGORY DESCRIPTION
Lifestages benefit programme Vaccinations, preventative care and screening
Day-to-day Day-to-day-cover for medicines and GP and specialist consultations
Enhanced rates for a range of minor procedures to be performed in the GP rooms, for convenience and to
In-rooms procedures
contain hassle and cost
Unlimited private hospital cover at any hospital and full cover with preferred specialists and up to 150% of
Hospitalisation
the Alliance-MidMed Rate for other specialists. Pre-authorisation is required
Specialist tests and treatment, including high-cost drugs, must be pre-authorised, as per the Benefits
Specialised treatment and tests
section herein. Call us on 0860 00 2101
We cover the 27 Chronic Disease List (CDL), and an extensive list of additional chronic conditions, as
Chronic condition management approved by the Board from time to time. The Scheme allows generous benefits for medicines that the
Board approves from time to time
Our emergency and trauma benefits provide for medical emergencies. A doctor and nurses are on call
Emergency and trauma 24/7. Call 0860 255 426, also when you need remote medical advice. Call the Midmed hospital
(0132 83 8700 (After hours: 0132 83 8701/2) if you have an emergency while in Middelburg
When a challenging medical issue exhausts your benefits, you may approach the Board for an Ex Gratia
Ex Gratia benefits
allocation, which benefits are awarded at the discretion of the Board
D. PERSONAL MEDICAL SAVINGS PLAN (PMSA) OR SAVINGS
5% of contributions are reserved into your Personal Medical Savings Plan (PMSA) which you can use to pay for benefits defined as PMSA benefits or
other allowable medical expenses, except the exclusions as defined in the Scheme Rules.
EMERGENCIES AND TRAUMA BENEFIT
Emergencies are covered in full. When you have an emergency, do the following:
Go to the nearest emergency service or hospital and present your membership card. You must inform us within 24 hours of the emergency
Call Europ Assistance on 0860 255 426 for telephone guidance in the While on the phone they will dispatch emergency medical care to you,
event of an emergency including air ambulances where it is necessary
In Middelburg, call the Midmed hospital 013 283 8700 if you require emergency medical attention
Elsewhere in South Africa (out-of-area), phone Europ Assistance at 0860 255 426
I) TRAUMA BENEFIT
If you were exposed to a traumatic event such as vehicle accidents, assault, hijacking, child abuse, armed robbery, family violence and animal
attacks, the emergency and counselling benefits might be accessed to deal with the event, without having to obtain pre-authorisation.
TABLE OF FREQUENTLY USED BENEFITS
THE COVER/BENEFIT BENEFIT NOTES MONETARY LIMIT 1234
A full list of benefits is specified in Annexure B of the Scheme Rules
EXCEPT WHERE DIFFERENTLY INDICATED:
1. Benefits are paid/refunded at the lower of cost or 100% of the Alliance-MidMed Rate.
2. Rand value limits are per annum per family.
3. Benefits are paid from the Major Medical Pool (MMP). If a member fully utilises benefits within the MMP.
4. Members may instruct the Scheme, in writing, to pay additional benefits from the Personal Medical Savings Account (PMSA) for valid
medical expenses.
We pay PMB benefits according to legislation.
Management programmes, treatment plans and protocols are best practice funding rules that the clinical team agree to, once they received treating
healthcare provider’s diagnosis and treatment options.
6BENEFITS
HOSPITALISATION *
In-patient: Accommodation in a general ward,
high care, intensive care, and theatre
• Pre-authorisation required
Subject to sub-limits,
Out-patient: Treatment at a hospital when you • Including medication, materials and
e.g. radiology and physiotherapy
are not admitted hospital equipment
Day hospitals
ALTERNATIVE TO HOSPITALISATION *
Sub-acute nursing facilities, step-down nursing • Maximum, six months in any calendar year
facilities, private nursing, rehabilitation centres, • Pre-authorisation required R46 625 per family member
hospices and home support centres • Treatment plans required
ALCOHOL AND OTHER DRUG DEPENDENCY TREATMENT
Co-payments may apply where non-PSP
Accommodation in a general ward Pre-authorisation required
facilities are used
AMBULANCE
In Middelburg - call the Midmed Hospital
ambulance service at Out of Area:
R3 841 per beneficiary per annum for
Ambulance • call Europ Assist (preferred provider)
non-preferred providers
• pre-authorisation required except in
an emergency
APPLIANCES
• Out of hospital appliances costing more than
Nebulisers, humidifiers, oxygen cylinders,
R500 are subject to pre-authorisation
glucometers, peak flow meters, R9 585 per family
• Humidifiers out of hospital require a
home ventilators
prescription by a health professional
CPAP machines No benefit
R18 400 per beneficiary every three years,
Hearing aids Subject to an independent Scheme evaluation
R9 200 per unit
AUTISM & ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
Autism & ADHD Subject to Managed Care Protocol
BLOOD, BLOOD EQUIVALENTS AND BLOOD PRODUCTS
Blood and blood products Subject to the hospital and Major Benefit
R20 878 per member family per annum
Management Programme
Blood equivalents
CONSULTATIONS: GENERAL PRACTITIONERS
In-hospital
Scheduled and unscheduled visits,
limited to a fixed number of consultations per
Out-of-hospital * R476 per consultation
family per annum: M - 6, M1 - 11, M2 - 15,
M3 - 19, M4 – 21, M5 - 25, M6+ - 27
• For minor In-rooms surgical procedures
- see page 15
Enhanced consultation fee • For Prescribed Medical Conditions, separate
additional consultations may apply. Contact
us on 0860 00 2101 for more information
CONSULTATIONS: SPECIALIST
Subject to pre-authorisation and to managed
In-hospital
care protocols
Limited to a fixed number of consultations per
The first consultation in a calendar year is paid
Out-of-hospital family per annum: M - 4, M1 - 8, M2 - 9, M3 - 9,
at 250% of the Alliance-MidMed Rate
M4 - 1, M5 - 11, M6+ - 11
DENTAL BENEFITS BENEFIT NOTES MONETARY LIMIT
GENERAL/CONSERVATIVE DENTISTRY
Consultations Two consultations per beneficiary per annum
X-rays: Intra-oral Four X-rays per beneficiary per annum
X-rays: Extra-oral One per beneficiary every three years
7BENEFITS
Two scale and polish treatments
Oral hygiene
per beneficiary per annum
Fillings Once per tooth in 720 days
Root canal therapy and extractions Subject to Managed Care Protocols
One set of plastic dentures (an upper and a
Plastic dentures lower) per beneficiary every four years. Subject
to pre-authorisation if approved by the Scheme
SPECIALISED DENTISTRY (A 10% CO-PAYMENT APPLIES TO SPECIALISED DENTISTRY AND PRE-AUTHORISATION IS REQUIRED)
Two partial metal frames (one upper and one
Partial metal frame dentures
lower) per beneficiary every five years
Three crowns per family per year and once per
Crown and bridge*
tooth every five years
Benefit for fixed comprehensive treatment,
Orthodontics*
limited to ages nine to 18
Periodontics* Register on the periodontal section of the DMP
Maxillo-facial surgery in the dental chair Subject to Managed Care Protocols
Implants No benefit No benefit
DENTAL ANAESTHETICS
Hospitalisation (general anaesthetic) No benefit
Laughing gas in dental rooms Subject to Managed Care Protocols
IV conscious sedation in rooms* Subject to Managed Care Protocols
• Dental benefits are paid at the Alliance-MidMed Rate, available at allianceenq@denis.co.za or at the Scheme offices in Middelburg
• Subject to the DMP clinical protocols and interventions
• Certain exclusions apply (including implants and any associated laboratory costs) – refer to the Exclusions list contained in Annexure C of the
Scheme Rules
• Pre-authorisation is required, including PMB, for dentures, crowns, orthodontics, periodontics and IV conscious sedation
• A 10% co-payment applies to plastic dentures, partial metal frame dentures, crowns and bridges, orthodontics, periodontics and maxillo-facial
and oral surgery in the dentist chair
LIFESTAGES BENEFIT (SEPARATE FROM THE MEMBER’S NORMAL BENEFITS AND PAID FROM THE MAJOR MEDICAL POOL)
IMMUNISATION AND VACCINATION PROGRAMME
Females between the ages of 9-25 years,
Cervical cancer vaccine three vaccines during a six month period,
once per lifetime
According to the Dept of Health recommended
Compulsory baby immunisations immunisation programme, for the first
12 years of life
Everyone, 60 and older, and persons whom our
Flu vaccination
clinical team contact to take the vaccine
Males between the ages of 9-14 years,
Male HPV (Gardasil) vaccine
two doses once per lifetime
Everyone, 60 and older, and persons whom our
Pneumococcal vaccination
clinical team contact to take the vaccine
Tetanus vaccine Everyone, once per year
EARLY DETECTION PROGRAMME
Blood sugar test Everyone, once per year (code 4050)
Females 50 years and older,
Bone density - dexa scan
once every three years
Everyone, 25 and older, once per year
Cholesterol test
(codes 4026, 4027, 4028 or 4147)
Colorectal cancer screening
Beneficiaries 50 years and older, once a year
(faecal occult blood test)
Infant hearing screening Younger than eight weeks old, once per lifetime
Mammogram Females 40 years and older, once a year
8Females older than 40, once per year
Pap smear
(code 4566)
Prostate-specific antigen (PSA) Males 40 years and older, once a year
Males older than 40, every two years
Prostate test (PSA)
(code 4519)
Should you have a family history of breast or prostate cancer, please contact our clinical team for guidance on prevention and screening.
We pay for prescribed female contraceptives and preventative dentistry, according to set protocols. Email us at service@alliancemidmed.co.za
for more information.
HIV/AIDS
• Subject to the HIV Management Programme
• Pre-authorisation required - contact us on
Treatment and care, including medicines
our dedicated confidential number
0860 00 2101, option 2
MATERNITY & INFERTILITY (REGISTRATIONS AND ADHERENCE TO THE MATERNITY PROGRAMME REQUIRED BY THE FIRST 3 MONTHS)
• First 6 months: 1 consultation per month
Maternity: Consultations, visits & delivery by
• Months 7 and 8: 2 consultations per month
GP, specialist or midwife
• Month 9: 1 consultation every two weeks
Maternity: Scans, accommodation,
• Pre-authorisation required
theatre fees, drugs, dressings, medicines and
• 3 (three) 2D pregnancy scans per pregnancy
materials, labour ward fees, etceteras
• According to the PMB rules
Infertility: Investigation and treatment
• Pre-authorisation required
MEDICATION
• Subject to the Medicine Management M - R5 500, M1 – R10 046, M2 - R11 672
Protocols M3 - R13 524, M4 - R15 246, M5 - R15 875,
Acute medication
• TTO Medication is included in the acute limit, M6+ - R17 608
but no co-payment applies for TTOs R10 levy, and a maximum R20 levy
• 100% of MRP
M0: R20 432, M1+: R42 739
Chronic medication - PMB and Non-PMB • Pre-authorisation required
Unlimited for PMB Conditions
• Call ChroniLine on 0860 119 553
12 purchases per family per year • Minimum R10 and a maximum of
Pharmacy advised therapy (PAT)
(schedule 1 & 2 medication) R158 per purchase
MENTAL HEALTH
IN-HOSPITAL
Accommodation in a general ward, • Subject to the Mental Wellness Managed
electro-convulsive treatment, medication, Care Programme and Specialist Diagnosis • R47 829 per member family for non-PSP
injection materials, hospital equipment, • Electro-convulsive treatments limited to • 100% of the cost for PMB treatment at PSP
consults and visits by GPs 12 treatments per annum
Specialist consults and visits 150% of the Alliance-MidMed rate
OUT-OF-HOSPITAL
• Subject to out of hospital specialist
Consultations and visits including consultation limits
clinical psychologist and social workers, • Mental Wellness Programme Protocols apply
and procedures Subject to a confirmed diagnosis by a suitably
qualified Psychiatric specialist
Included in the out of hospital specialist
Specialist consults and visits
consultations
NON-SURGICAL PROCEDURES AND TESTS (E.G. HEART SONAR, STRESS ECG, LUNG FUNCTION TEST)
IN-HOSPITAL
Performed by a GP Subject to PMB, Hospital and
150% of the Alliance-MidMed rate
Major Benefit Management Programme
Performed by a Medical Specialist
OUT-OF-HOSPITAL
Performed by GP M0: R5 358, M1+: R8 323
Subject to PMB, Hospital and Major Benefit
Management Programme
Performed by a Medical Specialist 150% of the Alliance-MidMed rate
9BENEFITS
NURSING SERVICES
Out-of-hospital Wound care only To R12 122 per member family
ONCOLOGY (CANCER TREATMENT)
Upon successful registration, the Scheme • Subject to the Oncology Managed
R500 000 per beneficiary overall limit unless
will pay all associated costs according to the Care Protocols
PMB applies
agreed treatment plan • Pre-authorisation required
OPTICAL BENEFIT (PER BENEFICIARY)
Paid from the Major Medical Pool
Composite consultation (Including refraction, a glaucoma screening, 100% of the cost, maximum R575
visual fields screening and biometric reading)
Frame
(The cost of a basic frame is funded from the Paid from the Major Medical Pool Maximum R1 254
Major Medical Pool. You may use up to the
additional amount allowed from your positive Paid from PMSA Maximum R2 404
savings if you want a higher-priced frame)
Paid from the Major Medical Pool
• Single vision lenses R481 per pair
• Bifocal lenses R1 463 per pair
Lenses - One pair of either
(We pay the cost of basic lenses. You may • Multifocal lenses R1 881 per pair
use up to the additional amount allowed
from your positive savings if you want a Paid from PMSA
higher-priced lens)
• Single vision lenses R656 per pair
• Bifocal lenses R836 per pair
• Multifocal lenses R2 370 per pair
Paid from the Major Medical Pool Maximum R836
Lens enhancements
Paid from PMSA Maximum R523
OR
Paid from the Major Medical Pool Maximum R1 254
Contact lenses
Paid from PMSA Maximum R2 717
Optical benefits are available every 24 months from the previous date of service. Choose either the spectacle OR the contact lens benefit.
Savings refunds are made to members, based on a detailed account including all the services rendered - split-billing is legally not permissible.
Savings refunds may not be made before the service date. Savings refunds are not automatically. Please submit your claims for savings refund to
service@alliancemidmed.co.za or from your mobile Member App. The Scheme does NOT refund broken spectacles. Contact lens benefits are also
subject to the 24 month cycle.
ORGAN TRANSPLANTS
• Subject to Public Hospital Protocols and
Evidence-Based Medicine
Harvesting of organ and transplantation -
• Detailed treatment plans are required Pre-authorisation required
post-operative anti-rejection medicines
• Pre-authorisation required
• Subject to PMBs
PATHOLOGY (BLOOD & OTHER TESTS TO DIAGNOSE ILLNESS) *
In-hospital Subject to hospital admission authorisation Unlimited
• Preferred provider laboratory
Out-of-hospital • 5% co-payment up to a maximum of R50 for M0: R5 672, M1+: R8 811
the use of a non-preferred provider
PROSTHESIS
To include:
• Stents (cardiac, peripheral and aortic)
Cardio/Vascular prostheses and appliances • Valves R55 124 per family per annum
• Pacemakers
• Implantable defibrillators
• Subject to failed conservative treatment
and the Joint Replacement Protocol R46 856 per family per annum,
Joint prostheses
• To include: Hip, knee, shoulder Subject to an R5000 co-pay
and elbow only
10• Subject to failed conservative treatment and
Risk Management
• To include:
• Spinal fixation devices (maximum two
(Orthopaedic) Spinal prostheses
levels unless motivated) R55 124 per family per annum
and appliances
• Fixation devices: non-spinal
• Implantable devices, disc prosthesis,
Kyphoplasty
• Bone lengthening devices
Neuro stimulators and deep brain stimulators R33 074 per family per annum
Internal sphincters and stimulators R52 919 per family per annum
Intraocular lenses R3 658 per lens per family per annum
External prostheses (not surgical implanted) R42 452 per family per annum
RADIOLOGY AND RADIOGRAPHERS (IN HOSPITAL)
M: R1 507, M1: R2 353, M2: R3 506,
General
M3+: R4 410
Specialised (e.g. MRI & CT Scans) Pre-authorisation required R11 768 per member family per annum
REMEDIAL AND OTHER THERAPIES AND ALTERNATIVE HEALTHCARE PRACTITIONERS
AUDIOLOGISTS, DIETICIANS, OCCUPATIONAL THERAPISTS, PODIATRISTS, HEARING AID ACOUSTICS,
SPEECH THERAPISTS & SOCIAL WORKERS
In-hospital Subject to Managed Care Protocols and Treat-
R4 872 per family per annum
ment Plans from referring doctor
Out-of-hospital
HOMOEOPATHY, NATUROPATHY, OSTEOPATHY, CHIROPRACTICS AND ORTHOPTICS
Consultations
100% of MRP Subject to available funds in the PMSA
Medication
PHYSIOTHERAPISTS AND BIOKINETICISTS
Except in ICU where benefits are unlimited,
In-hospital R6 959 per family per annum
subject to Managed Care Protocol
• R4 045 per family per annum
Out-of-hospital
• Subject to available funds in the PMSA
RENAL DIALYSIS
• Subject to the Disease Management
Acute and chronic Programme
• Pre-authorisation required
SURGICAL PROCEDURES (HEALTH PROFESSIONAL RATES) & MINOR IN-ROOMS SURGICAL PROCEDURES
• Subject to the hospital and Major Benefit
Performed by GP Management Programme
• Pre-authorisation required
Performed by Specialists • Excluding services provided in respect of
maternity and organ transplants
Minor In-Rooms: For easy access, affordability and confidentiality reasons the Scheme approved a list of small procedures that your doctor can
perform in the rooms, instead of in a hospital. We pay your doctor an enhanced fee for these services, which include:
Excision (surgical removal), aspiration
(removing the fluid with a suction tube) or
0857/0853 Bursae and Ganglia (cysts) injection (no aftercare). Excision, small Bursa or
Ganglion (cysts, usually around the knee
or elbow)
0244 Chemo-cryotherapy Benign lesions (wound, blister or a nodule)
Deep skin biopsy with
0237 anaesthetic suturing (stitches
or staples to close wounds)
Remove foreign bodies requiring incision,
0922 Hands
under local anaesthetic
110310 Lacerations or scars Radical excision of the nailbed
0305 Needle biopsy Soft tissue
0259 Removal of foreign bodies
0244 Repair of the nail bed
0307 Scars Minor procedures
Additional wound stitched at the
0308
same session
0301 Repair by a small skin graft
0315 Excision of large benign tumour
0311
Removal of a benign lesion by
0245 Skin
curetting first lesion
Drainage of subcutaneous abscess
0233
and Onychia
Removal of a benign lesion by
0255
curetting - subsequent lesion
0246 Treatment by Chemo-cryotherapy
Lesion by Chemo-cryotherapy -
0241
subsequent lesion
Lesion by Chemo-cryotherapy -
0242
maximum event
0243 Drainage of major hand or foot infection
0257 Intralesional injection, single
0223 Removal of foreign body - Chemo-cryotherapy
Removal of malignant lesions
0261
With or without local anaesthesia including
0300 Stitching of minor wounds
normal aftercare
GP rooms must comply with legal and An enhanced consultation fee of R536
Male circumcision in GP rooms
clinical requirements A facility fee of R1 075 per procedure
The Scheme will pay an Enhanced Consultation rate of R536 and a facility fee of R342 should the General Practitioner perform the listed minor
in-room surgical procedures in their rooms. Enhanced Consultations are limited to 3 (three) per annum. If not performed at the GP rooms,
an R1 500 co-payment applies.
HEALTH MANAGEMENT
F. PROGRAMMES AND ILLNESS MANAGEMENT
I. HOSPITALISATION
If either you or your dependant is hospitalised, please phone for pre-authorisation on 0860 00 2101, at least 72 hours in advance. In the event of an
emergency, please notify us within 48 hours of admission. Shorter notice will attract a co-payment of R1 500 to the hospital on the day of admission.
When you call for pre-authorisation, please have the following information ready:
• Your membership number
• Details of dependant requiring the treatment
• Name and address of admitting doctor
• The name and address of the referring doctor (where applicable)
• Date of admission
• Medical condition ICD 10 (diagnosis) code and/or CPT (procedure) code
• Type of procedure/operation (where applicable)
• Name of hospital or clinic
• Expected length of stay
II. MEDICINES
We have one of the most generous medicine benefits in the industry, and to maintain the benefit, require cautious use by all of us. Please avoid
unnecessary or inappropriate use or prescriptions that are too expensive compared to other similar products.
Because medicines account for about 35% of our expenditure, we have implemented measures to assist you, including Maximum Medical Aid
Price (MMAP), that sets a price limit on what the Scheme will pay for any group of medicines that have a similar clinical effect, allowing for access to
appropriate medicines, but loading co-payments on more expensive similar medicines.
12Generic substitution is a hotly debated topic. Our expert service provider evaluates the medicines, and where we offer access to the more cost-
effective “generics,” it is without compromising quality, and we urge you to discuss the preference with your doctor. You can also call Mediscor on the
numbers in the benefits table.
The government have also intervened and established a set price per medicine product and a set dispensing fee (the so-called Single-Exit Price).
Alliance-MidMed retains the MMAP price, that sets a realistic price for products within a specific group of medicines, allowing a choice of at least two
products. The Scheme will pay the lesser amount of SEP or MMAP. This list will apply to both the Acute and the Chronic Medicine Benefits.
CHRONIC MEDICINE PROGRAMME
The Chronic Medicine programme authorises payment of appropriate, high quality and cost-effective medicines. The following qualify for access to the
Chronic Medicine Programme:
• Medicines for life-threatening illnesses such as insulin-dependent diabetes
• Medicines used on an ongoing basis to treat disabling
• Chronic illnesses such as rheumatoid arthritis that significantly affect productivity and quality of life
• In exceptional instances, very expensive short-term medicines that will prevent other expensive treatment in future, such as hospitalisation
Access to the Chronic Medicines Benefit is restricted and requires a formal authorisation process to be followed. Note that certain “chronic conditions”
may not qualify for benefits. Call us on 0860 00 2101 to verify if your chronic medicines qualify for the benefit.
Typical exclusions are symptomatic conditions that should first be addressed through lifestyle changes and intermittent medicines used (e.g. irritable
bowel syndrome), or the milder forms of some conditions (for example, cholesterol medicines in otherwise low-risk individuals who should focus on
lifestyle changes).
Also, note that authorisation of your chronic medicines onto the programme does not constitute a guarantee of the payment of above tariff rates.
The day-to-day medicine benefit is paid from the MMP. When chronic medicine is then declined for use on the chronic programme, it will also not be
paid from the day-to-day medicine benefit. Your positive PMSA balance may be used to pay for this benefit.
ADMINISTERING THE CHRONIC MEDICINE PROGRAMME
We administer the chronic medicines programme through the Mediscor ChroniLine. If either you or a family member requires chronic medication,
you will need to do the following:
1. Make an appointment with your doctor for an examination and get a prescription
2. Take your script to your pharmacy
3. Should your provider (doctor/pharmacist) wish to register a new chronic condition/discuss certain medications with the clinical team/make changes
to existing medication or make a motivation they are requested to contact the Chroniline directly on 0860 119 553
4. Information about the condition/drugs such as test results per condition will be required in keeping with the Entry and Diagnostic criteria and Clinical
Rules, available on request
5. If all criteria are met, the doctor or pharmacist will be informed immediately of the outcome and the authorisation will be granted. You can claim
medication as soon as registration is approved
6. If the registration of the medication is rejected, or held in waiting because we await additional information, the doctor or pharmacist will be informed
of the reasons
If you are currently registered, you will only be required to renew your application once your authorisation has expired or if you have had a change in
the dosage or type of medication. Your authorisation may extend beyond the validity of your prescription (prescriptions are legally valid for 6 months).
When your repeat prescription is complete, please consult with your doctor, ensure that a thorough examination is done, and obtain a new prescription
from your doctor. Please ensure that you make copies and retain for your record purposes in the event of changing pharmacies.
Please enquire from Chroniline, or use the look-up at www.mediscor.co.za to see which medicines are covered by the Chronic Medicine Programme
or the Maximum Medical Aid Price (MMAP). If it is not covered, you will be required to make a co-payment upon collecting your script.
III. ONCOLOGY (CANCER)
We have contracted with ICON, a specialist oncology manager, who agrees on detail treatment plans with your treating specialist. Contact us on
0860 00 2101 should you need to access this benefit.
IV. LONG-TERM CHRONIC ILLNESS
V. PMB AND CDL
We cover the 26 Conditions prescribed in the Chronic Disease List (CDL) and a range of non-CDL chronic conditions. The CDL conditions include:
Cardiac dysrhythmias, Cardiac failure, Cardiomyopathy, Coronary artery disease, Hyperlipidaemia,
Cardiovascular
Hypertension
Dermatology/Skin disorder Systemic lupus erythematosus
Addison’s disease, Diabetes insipidus, Diabetes mellitus Type 1, Diabetes mellitus Type 2,
Endocrine
Hypothyroidism
Gastro-intestinal Crohn’s disease (excluding biologicals such as Revellex*), Ulcerative colitis
Haematology Haemophilia
Musculo-skeletal Rheumatoid arthritis (excluding biologicals such as Revellex and Enbrel*)
Multiple sclerosis (excluding biologicals such as Avonex, subject to protocols*), Epilepsy,
Neurology
Parkinson’s disease)
Ophthalmology Glaucoma
Psychiatric Schizophrenia, Bipolar mood disorder
13Renal Chronic renal disease
Respiratory Asthma, Chronic obstructive pulmonary disease, Bronchiectasis
VI. MAJOR/SPECIALISED ILLNESSES
As a rule, pre-authorisation is required when a procedure or treatment is paid from the Major Medical Pool. When you are considered a higher risk,
e.g. seniors or you suffer from a serious medical condition or multiple chronic conditions, we will ask you to attend a medical examination or go for a
second opinion before you undergo major surgery or treatment. Below, for reference, please find some examples and we encourage you to phone us
at 0860 00 2101 or email us at service@alliancemidmed.co.za so that we can assist you in accessing the best treatment and care:
Myelogram (spinal cord x-ray or CT scan), 48-hour halter EEG, Electro-convulsive therapy, Hyperbaric
Neurology
oxygen treatment
Cataract removal, Meibomian (a gland in the eyelid) cyst removal, Pterygium (growth on the cornea of
Ophthalmology the eye) removal, Trabeculectomy (surgically reduce pressure in a glaucoma patient’s eye), Treatment of
diseases of the conjunctiva (eye membrane and the inner eyelids)
Antroscopies (inspection of the sinus), Direct laryngoscopy, Grommets, Myringotomy (reliving pressure
Ear, Nose and Throat (ENT) in the eardrum), Nasal cautery (burning), Nasal scans and surgery, Functional nasal and sinus surgery,
Tonsillectomy
24-hour halter ECG, Blood transfusions, Carotid angiograms, Coronary angiogram, Coronary angioplasty
Cardiovascular
(restoring blood flow through the artery), Plasmapheresis (separation of blood cells)
Respiratory Bronchography, Bronchoscopy, Treatment of adult influenza, Treatment of adult respiratory tract infections
Cervical laser ablation, Colposcopy, Cone biopsy, Dilatation and curettage, Hysteroscopy, Incision and
Gynaecology drainage of Bartholin’s cyst, Marsupialisation (surgical removal) of Bartholin’s cyst (gland), Tubal Ligation
(permanent birth control)
Childbirth in non-hospital, Amniocentesis (using a needle to extract a sample of the fluid that surrounds
Obstetrics
the fetus in pregnancy)
Colonoscopy, ERCP (scope of the stomach), Gastroscopy, Oesophagoscope (examining the inside of the
Gastro-intestinal
throat), Sigmoidoscopy (internal examination of the colon)
Arthroscopy, Back and neck surgery, Bunionectomy, Carpal tunnel release, Conservative back and neck
Orthopaedic
treatment, Ganglion surgery, Joint replacements
Renal Dialysis
Urology Cystoscopy, Prostate biopsy, Vasectomy
Biopsy of a breast lump, Drainage of subcutaneous (under the skin) abscess, Removal of extensive
General procedures and treatment skin lesions (abnormal growth or appearance), Removal of minor skin lesions, Laparoscopy, Lymph node
biopsy, Nail surgery, Open hernia repairs, Superficial foreign body removal, treatment of headache
Please note that the cost of anaesthetics for anaesthetists for gastroscopies and colonoscopies are covered up to R550.00, and it is subject to
pre-authorisation. For all other out-patient procedures, the costs of anaesthetists (if any) are only covered if pre-authorised by us.
G. SPECIALIST SERVICE BENEFITS
I. DENTAL
We have appointed Dental Management Company to manage our dental care programme. They assist the Board by compiling a ruleset, managing
the benefit and dentist issues and queries and payment of our claims. We pay them a fixed fee for the service, and they continue to contribute to our
philosophy of ensuring access to quality care at an affordable price.
II. OPTICAL (EYECARE)
The professional staff at a leading university advised us about the Scheme’s optical benefits, and we manage the benefit in-house. If you have queries
or concerns, however, please contact us at 086 00 2101 for assistance.
ENHANCEMENTS
I. LIFESTAGES BENEFIT
Our generous Lifestages Benefit Programme provides for a compulsory Immunisation and vaccination programme and a range of additional
vaccinations, and an early detection programme to better engage members regarding their health risks.
The lifestyle programme is run under the Know-Your-Numbers – Know-Your-Health-Risks banner and focuses on improving your quality of life,
reducing your utilisation of health services, and reducing the overall costs of healthcare in the medium and then the long term.
The Lifestages benefits must be pre-authorised. Call us on 0860 00 2101 for more information.
Should you have a family history of breast or prostate cancer, please contact our clinical team, for guidance on prevention and screening guidance.
Note that we pay for prescribed female contraceptives and preventative dentistry, according to set protocols. Please email us at
service@alliancemidmed.co.za for more information.
14II. HOW DOES YOUR PERSONAL MEDICAL SAVINGS ACCOUNT (PMSA) WORK?
5% Of your contributions are allocated to the PMSA to provide for specific benefits such as chiropractors and naturopaths, and for day-to-day
healthcare expenses that are not covered by the Scheme. What you do not use in one year, will be carried over to the next year, or paid out to you (or
to your new medical scheme) five months after you have terminated your membership.
We distinguish between current year savings and prior year (positive) savings, and certain benefits (e.g. optical) have a maximum amount that may be
paid from the PMSA.
Except for benefits that only pay from the PMSA, other PMSA refunds must be authorised by you and certain benefits are not paid to health
professionals, but directly to you, who must pay the health professional.
On 1 January each year, you receive the full annual savings allocation and the amounts that have not been utilised from the previous year.
The total amount to be set aside in your PMSA for the year is calculated by multiplying the savings portion of your monthly contribution by 12 (or by the
remaining number of months in the year, if you join later than 1 January). The Scheme automatically allocates that portion of your monthly contribution
that applies to savings, to your PMSA.
This ‘upfront’ allocation is recalculated when dependants are added (the allocation increases) or removed (the allocation decreases) during the year.
If the amount claimed from your PMSA during the year exceeds the amount paid during the year (e.g. if a member or dependant resigns and the
recalculated allocation is less than the money already claimed from the PMSA), the difference will be regarded as a debt that is repayable to
the Scheme.
The PMSA has several benefits:
• You control your PMSA expenditure
• Unused PMSA balances (accumulated balances) can be carried over from one year to the next
• You can use your positive PMSA for valid claims when available MMP benefits are depleted
• Members’ portions of an account (for example where a Provider has charged above Alliance-MidMed Rate)
• On application, to pay for medical expenses which the Scheme is not liable for (for example extras on glasses, stale claims, etc.).
• Claims will be processed according to the date of treatment. Claims from the previous benefit year cannot be paid from the current year’s
PMSA. You may use the balance brought forward from the previous year to settle claims for the current benefit year
By law, providers may submit claims for services rendered to you for up to four months after the date of service. Consequently, Alliance-MidMed
Medical Scheme must provide for any claims that you may have incurred and that may still be outstanding during this time. Therefore, any credit
balance in your PMSA (if applicable) will only be refunded to you or transferred to your new medical scheme five months after termination of
your membership.
III. EX GRATIA BENEFIT
The Scheme manage benefits through monetary limits, best practice medical standards and guidelines, limits on the number of consultations and
medicine, clinical evaluation by a team of medical personnel trained in medical funding evaluation and affordability criteria.
Members who require additional benefits can use their Personal Medical Savings Account (PMSA) if it is not a Scheme Exclusion (the Medical
Schemes Act determine that exclusions may not be paid from the Major Medical Pool or from the PMSA).
Members can also apply for Ex Gratia benefits, which are evaluated by a clinical team and then considered by the Board of Trustees. Please contact
us on 0860 00 2101 or visit the website (www.alliancemidmed.co.za) for more information on the Ex Gratia process.
IV. MINOR IN-ROOMS SURGICAL PROCEDURES
A list of minor surgical procedures are included in the benefits table above. An enhanced professional fee and a facility fee is payable to the General
Practitioner who perform these procedures in the rooms.
The reason for this is that the facility fees at hospitals are far more expensive, without rendering any additional benefit.
V. PRE-AUTHORISATION-REQUIRED
Most of the benefits in the MMP will be subject to pre-authorisation. Please call 0860 00 2101 also when you are unsure whether you
should pre-authorise.
Note that the following do not require pre-authorisation:
• Tonsils
• Grommets
• Normal delivery
• Hysterectomy
• Sterilisation
• Cholecystectomy
• Bunions
• Cataracts
• Breast biopsy
• Varicose veins
We reserve the right to implement utilisation controls where health professionals seem to use the service more than usual.
VI. PERSONAL HEALTH ADVISOR SERVICE
Also, the Emergency Call Centre introduces its Health Access Programme, including Health counselling, an audio health library and service
provider selection. You may access these and many other services through the Scheme’s emergency number 0860 255 426 (ALLIAN(CE)).
The telephonic services include the following:
• General medical advice and information
• Advice on chronic conditions (e.g. high blood pressure, epilepsy, etc.)
• Advice on allergies and poisons
• Advice on traveller’s immunisations and tropical diseases
15IMPORTANT BENEFIT MANAGEMENT MATTERS
H. PREFERRED SERVICE PROVIDER SCHEDULE
SERVICE
Emergency management and evacuation Europ Assistance
Alcoholism and drug dependency Please call us at 0860 00 2101 for information
Pathology Ampath
Oncology ICON
Psychiatric facility Denmar, Vista Clinic and Riverfield Lodge
Medicine management Mediscor
I. CO-PAYMENT SCHEDULE
BENEFIT CO-PAYMENT
R1 500 co-payment if not authorised 72 hours before a planned procedure
Hospitalisation: In-patient
or within 24 hours following an emergency
R50 co-payment per out-patient visit. If the treating doctor classifies that
Hospitalisation: Out-patient out-patient visit as a medical emergency or if you are admitted to the
hospital directly from the emergency centre, NO co-payment is applicable
Alternative healthcare practitioner R10 co-payment per consultation
R10 co-payment per consultation and any fees charged over and above
Consultations: General practitioner: Out-of-hospital the Alliance-MidMed rate. Unscheduled consultations will be for the
member’s account
Dentistry See Dental Benefit Guide (see page 19)
5% co-payment up to a maximum of R50 if Preferred Service Provider
Out-of-hospital pathology and medical technology
Laboratory not used
Unless services are at a PSP, a co-payment equal to the difference
Organ transplant between the actual cost incurred and the cost that would have been
incurred had the PSP been used
J. TRAVEL ABROAD
We do not provide international travel benefits, and if you incur costs abroad that the Scheme would ordinarily pay for in South Africa, and for which
an insurer has not refunded you, we will refund you in South African Rands at the exchange rate on the date of the invoice, in a South African bank
account. Submit your claims within one month of service.
For international travel insurance, contact your bank, if you have a credit card, or Google search “International Travel Insurance, South African Citizen.”
Should you travel abroad for an extended period and require advanced supplies of your chronic medicines, please contact us at
service@alliancemidmed.co.za at least three weeks in advance. We will require a copy of your flight tickets to authorise the advance supply.
Please also note specific Customs requirements when you take medicines on international travel.
K. DEALING WITH EMERGENCIES AND TRAUMA
Alliance-MidMed appointed an independent international medical emergency specialist to manage and coordinate our emergencies country-wide.
Their task is the professional stabilisation, appropriate evacuation, and transport of emergency patients to the nearest facility that can treat
your injuries.
Different responses are required for various emergencies and associated trauma. Below is a quick guide:
I. WHAT WE COVER
Incidents of physical and psychological emergencies and trauma, including:
• Bodily injury & medical (e.g. heart attack, poisoning, animal bite etc.) • Assault and child abuse
• Motor vehicle accidents and hit & run • Crime-related trauma
• Hijacking/Robbery • HIV exposure through rape or needle stick injury
Note that the cover includes:
• Shock and counselling treatment
• Where appropriate, the escorted return of minors, inter-hospital transfers and compassionate visits
• In the event of sexual crimes, we provide prophylaxis (prevention of HIV contraction after exposure), and Anti-Retroviral medicines
• Emergency transport is also, in the judgement of our specialist emergency manager, available for victims of emotional harm, e.g. hijackings
II. IDENTIFICATION
1. Ensure that you always have a membership card on you for when emergency strikes.
2. Place a copy of your membership card - from and back - in the cubbyhole of your vehicle. Emergency services will look there for identification.
Remember this when your children travel with others.
3. Ensure that your vehicles have emergency stickers which you can obtain for free from us on 0860 00 2101 or service@alliancemidmed.co.za.
Please place the stickers on side windows towards the back of your vehicle - they are less likely to be destroyed in an accident.
16III. IMMEDIATE ACTIONS
DEAL WITH THE EMERGENCY ENSURE ACCESS TO BENEFITS AND PAYMENT OF ACCOUNTS
Who to contact Call 0860 255 426 Contact the Scheme at 0860 00 2101 within 24 hours
• Guide you telephonically through the immediate crisis • Authorisation for hospital treatment after you have been stabilised
• Dispatch appropriate emergency transport to you • Action third-party cost recovery processes
What they do
• Identify the most appropriate hospital where the • Contact your next of kin where necessary
emergency transport should take you to
IV. ADDITIONAL REQUIREMENTS
Where another person, through their actions or failure to act (e.g. an animal bite), cause your injury, we require a SAPS case number to initiate
the recovery of the medical expenses. We will recover the medical costs from you if you fail to provide us with the SAPS case number or to fail to
cooperate in this process fully.
L. WORK INJURIES, MOTOR VEHICLE ACCIDENTS AND THIRD-PARTY INJURIES
The Workman’s Compensation Fund pays the cost of injuries sustained at work, and the Motor Vehicle Accident Fund pays the cost of injuries
sustained in a motor vehicle accident. If you sustained injuries as a result of the actions or failure to act by another person or party, then you are
required to initiate a case to recuperate the medical costs from that person. Failure to act may result in the Scheme recovering the costs from you.
Work injuries Motor-vehicle accidents Third party claims
The cost of the first 7 (seven) days The cost of the first 7 (seven) days
Your employer must arrange with the after your injury. Additional cover after your injury. Additional cover
Workman’s Compensation Fund to pay will be considered once you have will be considered once you have
for the costs of work injuries. We will appointed a legal representative and appointed a legal representative and
What we cover
recover the cost of work injuries from provided us with an undertaking to provided us with an undertaking to
you if we become aware that you did assist the scheme in recovering the assist the scheme in recovering the
not declare that you had a work injury medical costs from the Motor Vehicle medical costs from the Motor Vehicle
Accident (MVA) Fund Accident (MVA) Fund
Your employer and the Scheme The SAPS, the MVA and the Scheme The SAPS, the Scheme
Who to report to?
(within 48 hours) (within 48 hours) (within 48 hours) and your insurer
Assault, stab wounds, sports injuries,
injuries at school, and the loss of
Hearing aids and other injuries,
functions like hearing and sight. It may
diseases and illnesses, (occupational Broken limbs and other injuries,
also involve injuries or illnesses that
Typical costs asthma, including chronic medicines), illnesses, and loss of functions like
you incur while undergoing treatment
and loss of functions like hearing and hearing and sight
by a medical professional or in a
sight. (glasses), prostheses, etceteras
hospital, e.g. fall or infection acquired
while in hospital
Contact us at 0860 00 2101 and provide the following:
• Your member number
• The principal member’s surname, initials and first name
• The full name(s) of the person(s) injured
What actions to take?
• The SAPS case number where applicable
• The date the injury was sustained
• The details of the injury
We may require further information or reports from you
We require you to declare and contract with the Scheme for recovery of the cost of these benefits, including:
1. Written confirmation if there was an injury as stated above where you had not declared such to us when the injury occurred, and to recover such
medical costs and pay it back to the Scheme.
2. The written appointment of a legal advisor to recover the medical costs from the MVA Fund or from another third party on behalf of the Scheme.
Our attorneys will liaise with your representatives to recover the medical costs for the Fund. However, you remain responsible for ensuring that the
Scheme receives the refunds.
3. When we suspect that you are participating in dangerous activities or professional sport, including motocross, cave diving, sky diving, motorbike
racing, etc. If you participate in dangerous sports or activities, the injuries that you sustain as a result, may not be covered by the Scheme and
require that you take out insurance. Please refer to the Scheme exclusions list (Annexure C) or contact us.
Contact us on 0860 00 2101 or service@alliancemidmed.co.za if you are unsure about an activity/injury and send us the documentation within
seven days to ensure continued cover.
M. HOW TO MANAGE YOUR CARE, COSTS AND OUT-OF-POCKET EXPENSES
Some actions that will ensure you get the best care and limit your costs:
• Call the Scheme at 0860 00 2101 • Generic medicine is not the same as cheap
• Call the Europ Assist number at 0860 255 426 for after-hour emergency • Use the lifestyle benefits
assistance • Insist on a check-up when you renew your six-monthly prescription
• Call Europ Assist at 0860 25 5426 for after hour nurse and • Keep record of your doctor’s visits and the discussions
doctor advice • Insist on in-rooms treatment
• Know your numbers – know your health risks • Share your experiences with us
• Understand your treatment and care • Call us at 0860 00 2101 when you have a bad reaction to treatment
• Know the full cost of treatment • Contact the anesthetist 48 hours before your treatment for their cost
• Ask for second opinions • Consider GAP cover product to cover additional in-hospital expenses
• Lifestyle and nutrition is the preferred and sustainable first
healthcare option
17N. MANAGING FRAUD, WASTE AND ABUSE
Alliance-MidMed implemented measures to detect and manage Fraud, Abuse and Wastage (FAW) of benefits.
We do need your assistance, and we have appointed BeHeard, to manage to report FAW because they proved to have excellent reporting and
follow-up as well as the protection of persons who do report these incidents.
If you are aware of a practitioner or member abusing the benefits, please report, anonymously if you choose, to our Fraud Hotline -
0860 040 040 or mail@beheard.co.za. The FAW reporting service is confidential and free.
Remember: the greater the loss incurred through fraud, the higher your contributions become to help cover this loss.
ADMINISTRATION AND SELF-HELP
P. PAYMENT OF ACCOUNTS AND CLAIM SUBMISSIONS
I. SUBMISSION OF CLAIMS
You can submit claims in multiple ways.
HAND DELIVER EMAIL POST ALLIANCE-MIDMED MOBILE APP AT THE EMPLOYER
Ask your employer to
contact us to collect your
21 Dolerite Crescent, Download the App from the I-store
PO Box 1463, Faerie documents or
Aerorand, Middelburg, service@alliancemidmed.co.za or the Google App Store and scan
Glen, Pretoria, 0043 drop it off at our office at
Mpumalanga, 1055 claims directly into the App
the Columbus Stainless
Time Office
II. CLAIMING AND PAYMENT PROCEDURES
In most instances, your Health Professional will submit claims to us directly. More than 90% of health professionals submit claims online through
electronic data interchange (EDI) batch claims and real-time/online claims. Most EDI claims are processed and ready for payment within three days
and payments are made twice a month.
If your Health Professional charges at the Alliance-MidMed Rate, and you have not paid them, we will settle the account directly with them. There are
exceptions, like optical payments. If your Health Professional does not charge Alliance-MidMed Rates, please ask them to contact us at 0860 00 2101
to discuss payment options.
Please ensure that you know what your healthcare professional will charge before receiving the care/treatment. Settle co-payments directly and
continue to check your statements and respond to suspicious transactions, claims values, repeat visits, and the like.
It remains your responsibility to ensure that claims are submitted correctly and that the claims which appear on your statements are legitimate.
For a claim to qualify for payment, we require at least:
• Membership number
• The surname and initials of the principal member
• Name and date of birth of the dependant who received the treatment (this must be the same as on your membership card)
• Date of treatment
• Doctors’ practice number (must be a valid practice number)
• Tariff code and ICD 10 code
• Cost of service (including all costs, since split-billing is not allowed)
For medicine claims we require the following additional information (most pharmacies submit claims electronically, and therefore you will seldom need
to refer to this):
• Name of medication
• Quantity/Dosage
• Nappi code
• The referring practice number
Dental treatment often requires additional work by a dental technician. The technician charges the dentist, who then adds the claim amount to
your claim. We do experience challenges when the technician claim is not attached, or when it is incomplete, e.g. your name and details are missing.
For hand-delivered copies, please ensure that you keep copies of your claims in the event of the original being lost.
If you have already paid an account, please submit the account and proof of payment with the claim, which we require to refund you.
Given the increasing amount of fraud, we do not make payments by cheque, and we only change bank account details after a rigorous check.
Please ensure that we have your proper bank account details on record.
III. WHEN TO EXPECT PAYMENT
The law requires that we pay claims within 30 days; however, we pay claims twice a month. Exceptions apply from time to time;
e.g. if we obtain better prices.
We always try and expedite refunds to members who have settled claims in cash. If you have paid cash, or you are charged above the
Alliance-MidMed Rate, we will refund you directly.
IV. HOW WILL I KNOW WHAT WAS PAID?
• We send a statement to you at the end of each month
• Register on the Alliance-MidMed website and view your statement electronically
• Download and register on the Alliance-MidMed Mobile App and track your claims in real-time
18You can also read
